---
kind: "section"
citation: "45 C.F.R. § 152.19"
title: "45"
number: "152.19"
heading: "Covered benefits."
url: "https://uscodex.org/cfr/45/152.19"
---

# §152.19. Covered benefits.

- (a) **Required benefits.** Each benefit plan offered by a PCIP shall cover at least the following categories and the items and services:
  - (1) Hospital inpatient services
  - (2) Hospital outpatient services
  - (3) Mental health and substance abuse services
  - (4) Professional services for the diagnosis or treatment of injury, illness, or condition
  - (5) Non-custodial skilled nursing services
  - (6) Home health services
  - (7) Durable medical equipment and supplies
  - (8) Diagnostic x-rays and laboratory tests
  - (9) Physical therapy services (occupational therapy, physical therapy, speech therapy)
  - (10) Hospice
  - (11) Emergency services, consistent with [§ 152.22(b)](/cfr/45/152.22.md?p=b), and ambulance services
  - (12) Prescription drugs
  - (13) Preventive care
  - (14) Maternity care
- (b) **Excluded services.** Benefit plans offered by a PCIP shall not cover the following services:
  - (1) Cosmetic surgery or other treatment for cosmetic purposes except to restore bodily function or correct deformity resulting from disease.
  - (2) **Custodial care except for hospice care associated with the palliation of terminal illness.**
  - (3) In vitro fertilization, artificial insemination or any other artificial means used to cause pregnancy.
  - (4) Abortion services except when the life of the woman would be endangered or when the pregnancy is the result of an act of rape or incest.
  - (5) **Experimental care except as part of an FDA-approved clinical trial.**

## Notes

### Authority

Authority: Sec. 1101 of the Patient Protection and Affordable Care Act (Pub. L. 111-148).

### Source

Source: 75 FR 45029, July 30, 2010, unless otherwise noted.